VOLUNTEER APPLICATION
AND APPOINTMENT FORM
CSU FRESNO DEPARTMENT OF HUMAN RESOURCES
Please print clearly, in pen. All fields must be filled out. Completed forms must be received in the Human Resources office
1 week prior to appointment to allow for processing. Incomplete or late forms will be returned to the department.
APPLICANT INFORMATION
If volunteer is a current or former student, staff or faculty member, Campus ID is required.
Campus ID #:
Full Name:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
Home Phone:
(
State
ZIP Code
Email:
)
Emergency Contact:
Phone: (
)
Are You Under the Age of 18? ☐ YES
☐NO
If “YES” Provide Birthdate and attach Parental Release Form:
DEPARTMENT INFORMATION
Department:
Effective Start Date:
End Date (NOT TO EXCEED 1 YEAR):
Supervisor:
Campus Phone: (
)
Assignment Duties:
Will Volunteer be traveling on university business?
☐YES
☐NO
Will the Volunteer need to drive a vehicle on university business?
☐YES
☐NO
Will the volunteer have responsibilities that require him/her to possess a license, degree, credential or other
certification in order to perform the job? (If yes, list certification)
☐YES ☐NO
If one or more of following questions are marked “Yes” a background check, including criminal records, will be
required:
☐YES ☐NO
1. Will the volunteer have regular and unsupervised duties for the care, safety, and security of
people (including children and minors), animals, and CSU Property?
☐YES ☐NO
2. Is the person identified as a mandated reporter of child abuse and neglect under Executive Order
1083 and California Penal Code §11165.7(a).
☐YES ☐NO
3. Will the volunteer have the authority to commit financial resources of the university through
contracts greater than $10,000?
4. Will the volunteer have regular access, for any purpose other than the routine
solicitation and processing of credit card applications in a retail establishment, to all of
the following types of information of any one person:
 Bank or credit card account information
 SSN
 DOB
 Regular access to cash totaling $10,000 or more
☐YES ☐NO
☐YES ☐NO
5. Will the volunteer be responsible or have access to or possession of building master or sub -master
keys for building access?
☐YES ☐NO
6. Will the volunteer have regular, unsupervised access to controlled or hazardous
substances? Examples of this are: Dispenses prescription medication, maintains drug
formulary, access to drugs, access to potentially hazardous chemicals
☐YES ☐NO
7. Will the volunteer have access to and responsibility for level 1 sensitive data for faculty,
staff, students or alumni as defined either:
A. An individual’s first name or first initial and last name in combination with any one or more
of the following data elements, when either the name or the data elements are not
encrypted:
a) Social Security Number
b) Driver’s license or California identification card number
c) Account number, credit or debit card number, in combination with any required
security code, access code, or password that would permit access to an individual’s
financial account
d) Medical information
e) Health insurance information
B. Access to another user name or email address, in combination with a password or security question
and answer that would permit access to an online account of another person.
☐YES ☐NO
8. Will the volunteer have control over campus business processes, either through functional
roles or system security access?
Volunteer Acknowledgement
This is to acknowledge that I desire to volunteer my services, performing duties similar to those listed above and that
services rendered by me will be at the direction of the above named supervisor. I will not be compensated for these
services. If applicable, I hereby authorize and request any law enforcement agency, or other persons having personal
knowledge about me, to furnish California State University (CSU) Fresno or its authorized agent with information regarding
criminal convictions or other information in their possession regarding me in connection with my volunteer role in a
sensitive assignment. I agree that a photocopy of this information can be furnished to the CSU, and that it will have the
same authority and authenticity as the original (for more information regarding the CSU background check policy please
visit our website at www.csufresno.edu/hr). Further, I understand that I serve at the pleasure of my supervisor and can
be terminated from my volunteer position at any time.
Volunteer Signature:
Date:
Dept. Head or Dean Signature:
Date:
STATE PRIVACY NOTICE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the CSU to provide the following information to individuals
who are asked to supply information about themselves:
The principle purpose for requesting and collecting the personal information on this form is to conduct background checks. CSU policy and federal
statute authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory.
The personal information will be kept confidential and used only in accordance with applicable laws.
The personal information will be given to government enforcement agencies if these agencies request such information, or as otherwise required
by law.
Information Practices Act Notice (Civil Code § 1798.17)
This information is being requested by CSU Fresno. CSU Fresno is authorized to maintain this information pursuant to Education Code §§ 89500,
89535. Submission of the information requested on this form is mandatory. Failure to provide the requested information will mean that you will be
ineligible for the position you are seeking. The principal purpose for which this information is to be used is to assist the University in evaluating
your eligibility, qualifications, and suitability for the position you are seeking. You have a right of access to records containing personal information
maintained by CSU Fresno. The name, business address and telephone number of the person at CSU Fresno who is responsible for maintaining the
requested information and will be able to inform you of the location of this information is: Ryan Sepulveda, CSU Fresno Department of Human
Resources, 4150 N. Maple, Fresno CA 93740, 559-278-2032.
CSU FRESNO DEPARTMENT OF HUMAN RESOURCES M/S JA41
08/2015
Parental Consent Form for
Campus Volunteers
CSU FRESNO DEPARTMENT OF HUMAN RESOURCES
Please print clearly, in pen. All fields must be filled out. Completed forms must be received in the Human Resources office
1 week prior to appointment to allow for processing. Incomplete or late forms will be returned to the department.
To be completed and signed by parent/guardian of volunteer if volunteer is under 18 years of age
Event/Activity:
Date:
Volunteer Name:
Last
First
M.I.
Address:
Street Address
City
Apartment/Unit #
State
ZIP Code
Health & Accident Insurance Contact:
Emergency Contact:
Policy #:
Phone: (
)
I, _____________________________, being the parent or legal guardian of _________________________________
(the “Minor) hereby consent to and authorize the Minor to act as a volunteer for California State University (CSU)
Fresno.
I acknowledge and agree that activities performed by the minor as a volunteer will be performed strictly on a voluntary
basis, without any pay, compensation, or benefits. I agree and understand that the Minor must comply with the rules
and regulations established from time to time by the CSU and that failure to do so may result in the Minor’s immediate
removal as a volunteer.
I am aware of the nature of the activities to be performed by the Minor as a volunteer. I agree that all volunteer
activities are to be performed by the Minor at the Minor’s risk and I assume full responsibility therefore.
On behalf of myself, the Minor, and our r espective heirs and personal representatives, I agree to indemnify and hold the
State of California, the Trustees of the California State University, CSU Fresno and all of its officers, employees,
representatives and volunteers free and harmless from and a gainst all claims, damages, losses and expenses, including
attorney fees, that my minor child may sustain while participating in the volunteer activity. I hereby release and
discharge the CSU and the Trustees of CSU Fresno and all of its officers, employe es, representatives and volunteers from
any and all claims, demands, causes of action of any nature or cause, for any such injury or damage incurred or suffered
by the Minor.
Parent/Legal Guardian Signature
I have carefully read this agreement, waiver and release and fully understand its contents. I am aware that this is a release of
liability and a contract between CSU Fresno and myself and I sign it of my own free will.
Print Full Name:
Signature:
Date: